Improve Texas’ Perinatal Care System

Testimony by Michael E. Speer, MD

House Public Health CommitteeHouse Bill 15Wednesday, March 13, 2013

Thank you, Madame Chair, and members of the committee for the opportunity to testify. I am Michael Speer, MD, a practicing neonatologist and president of the Texas Medical Association (TMA). I also am a member of the Neonatal Intensive Care Unit (NICU) Council.

I am testifying on behalf of TMA and the Texas Pediatric Society (TPS), who are strongly in favor of the committee substitute on House Bill 15. The bill would establish a perinatal advisory council that would develop statewide maternal and neonatal levels of care designations with the goal of improving the quality of care and birth outcomes for mothers and babies.

Texas is making great strides toward improving the health care of mothers and babies. Over the past several years, lawmakers — with support from physicians, hospitals, and patient advocates — have championed forward-thinking initiatives to reduce infant mortality and preterm births. This includes the Healthy Texas Babies Initiative, which aims to reduce infant mortality using evidence-based interventions; a Medicaid policy to eliminate payment for non-medically necessary inductions before the 39th week of gestation; and the establishment of the NICU Council in 2011 to shepherd development of a regional neonatal care system.

As a result of the state’s efforts, Texas’ preterm birth rate gradually declined from a high of 13.7 percent in 2006 to 12.8 percent in 2011. [1] This is important progress, yet Texas can and must do better. The March of Dimes set a goal for Texas to achieve a preterm birth rate of 9.6 percent by 2020. Babies born prematurely not only have a higher risk of dying within the first year of life, but also are more likely to have ongoing health issues, including developmental delays and respiratory illnesses such as asthma.

Very low birth weight (VLBW) infants represent less than 2 percent of U.S. births but account for 55 percent of infant deaths.[2] Studies show conclusively that when these babies are born in a Level III or higher neonatal care unit, which provides the highest level of care, they are less likely to die and have better long-term health outcomes. Last year, in one of the largest studies published to date, researchers found that very premature babies (born before 32 weeks’ gestation) and moderately premature babies (born between 32 to 37 weeks’ gestation) born in Level III or higher NICUs were as much as 300 percent more likely to survive.[3] The study authors noted their results did not mean every hospital needed an advanced NICU; there would not be enough premature babies to fill them. Rather, states should use the data to develop regional systems of care.

TMA and TPS strongly believe that the development of statewide maternal and neonatal standards of care, as outlined in HB 15, is essential to the state’s efforts to further reduce preterm births and maternal morbidity and mortality.

While Texas has some of the finest hospitals and physicians in the country, without a standard set of designation criteria for maternal and neonatal services, the public cannot determine whether a facility is equipped to provide the most appropriate care. Further, standardization of designation criteria will allow Texas to compare outcomes across facilities, which is necessary for physicians and hospitals to implement targeted strategies for improvement.

The perinatal council’s role will be to establish evidence-based maternal and neonatal designations that any hospital will have the ability to pursue. As the bill moves through the process, we respectfully recommend clarifying language in the bill that the intent of the new Texas perinatal system is not to restrict the development of new NICUs or OBGyn units. Only hospitals and their medical staffs should determine whether to pursue a particular designation.

Further, we would like to work with you to further refine the language relating to payment issues. Specifically, we support amending the bill to clearly prohibit payment differentials for hospitals or physicians providing the same level of care, and to instruct Texas Medicaid to work with the council to address other Medicaid payment barriers that may impede the development of an effective and cost-efficient perinatal system. For example, current Medicaid payment policies impede appropriate transfers between hospitals, such as the transfer of a mother and/or baby from a higher-level facility to a community hospital when tertiary care is no longer needed, but inpatient care is.

Lastly, a statewide perinatal system must be designed to address the needs of preterm babies and their mothers. TMA and TPS strongly support development of maternal levels of care in addition to those for NICUs. A hospital capable of caring for the sickest babies also should have the ability to care for high-risk mothers. As noted above, it is the delivery of a very preterm baby at an appropriate NICU that is key to improving birth outcomes. When the mother delivers a premature baby at a separate facility, then the baby is transported to the higher-level NICU, the baby’s outcome diminish greatly. A hospital should not be required to have the same maternal designation as its neonatal one, but the designations should be compatible. In other words, a hospital capable of caring for the sickest premature babies should also have the ability to care for a high-risk mother.

The hospitals have raised concerns that there is insufficient evidence to develop criteria for maternal levels of care. However, the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal and Fetal Medicine (SMFM) have developed recommendations. More than two dozen states use these recommendations in their perinatal systems. Yet, we acknowledge that the maternal standards are not as detailed as those for NICUs. ACOG and SMFM will be releasing more specific criteria later this year. To address hospitals’ concerns, the committee substitute directs the perinatal advisory council to stagger development of the standards, beginning with release of the neonatal standards by 2017, but delaying initiation of any maternal standards until 2019.

Thank you again for your leadership on this important issue. TMA and TPS look forward to working with you on the development of a Texas perinatal care system. We urge your support for the committee substitute of HB 15.

[1]March of Dimes Peristats, 2012 Report Card for Texas; numbers based on preliminary analysis of 2011 data from the National Center for Health Statistics.